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EVOLVE.ELSEVIER EHR
Chapter 1 Vocab
| Term | Definition |
|---|---|
| Account Ledger | Lists services provided, payments made by the patient, reimbursement recieved from the patient's insurance company,adjustments and outstanding balances owed |
| Audit | A review of employee activity within the EHR (what files were accessed and why) |
| Chief Complaint | The paitient's main reason for showing up to the office |
| Clinical Decision Support (CDS) | Tools within the EHR to improve patient safety and comply with COC |
| Continuity of Care (COC) | A part of quality control that looks at the planning and coordination of care, the communication of eveyone that is a part of the patient's care team and the accessibility/transferability of that information (Interoperability) |
| Computerized Provider Order Entry (CPOE) | Function that allows a provider or a member of the patients care team to enter the ordered tests and medications using an automated format (REDUCES: prescribing errors, delays, duplications of care and can simplify the billing and inventory process) |
| Copayment | A fixed sum of money paid by the patient at the time services are rendered (Determined by the insurance company) |
| Daysheet (Day Journal) | A register for all daily business transactions (Patient services, payments, and adjustments) |
| Documentation (Also called a "Chronologic Record") | When you list all of the information found in the S.O.A.P. Notes |
| Electronic Health Record (EHR) (When this term is used can be talking about an electronic health record AND to a SYSTEM that manages EHRs) | A record that manages all patient information including patient contact information, legal documentation, demographics, and administrative data |
| Electronic Medical Record (EMR) (Electronic version of a paper record) | A type of EHR that allows the patient's care team to better manage a person's PHI |
| Electronic Transcription | Data entry into the EHR using handwritten recognition, voice recognition, electronic sentence building, scanning and other means |
| Encounter | A documented interaction, or visit between a patient and any of their providers |
| Interoperability | The ability of different EHR systems to share information in compatible formats |
| Meaningful Use (MU) (Part of the Federal EHR incentive program) | Providers will recieve incentives from the government if they can prove that they use EHR in meaningful and useful ways |
| Office of the National Coordinator for Health Information Technology (ONCHIT) | Coordinates the effort to implement health information and technology and the electronic exchange of health information |
| Patient Information Form | Form used to gather data about the patient, including demographics, medical insurance and emergency contact information |
| PracticeManagement Software (PMS) | Software used in a medical office to accomplish (nonclincal) administrative tasks, including entry of patient demographics, record keeping for insurance and other billing transactions, appointment scheduling and advanced accounting functions |
| Structured Data Entry | Documentation using controlled vocabulary via drop down menus, preloaded data, radio buttons and sentence builders |
| Superbill/Encounter Form (Main source of information used to create insurance claims) | An itemized form used to document services provided to the patient and the diagnoses for those services |
| Third party payer | A party other than the patient, spouse, parent or guardian who is responsible for paying all or part of the patient's medical costs |
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